Septal-myocutaneous flap technique for lower lid blepharoplasty

Lower lid blepharoplasty can present a significant challenge to the facial plastic surgeon. Routine findings of periorbital fat herniation and dermatochalasia of the lower lid are often associated with the presence of more occult findings, e.g., tarsoligamentous laxity and ectropion. Traditional surgical approaches to the aging lower eyelid utilize the skin flap, the skin-muscle flap, and the transconjunctival technique. The limitation of any one of these procedures alone is that of not addressing the multiple problems of the aging eyelid; this may lead to common postoperative problems of lower lid blepharoplasty, including lid retraction, lagopthalmos, scleral show, rounding of the lateral canthus, and ectropion. We present an integrated surgical solution to the functional and anatomical defects of both the anterior and posterior lamellae, and, when indicated, lateral canthal support. The procedure incorporates a small lateral subciliary and lateral canthal incision with a myocutaneous advancement flap developed in a plane deep to the orbital septum, combined with transconjunctival blepharoplasty for removal of herniated orbital fat. It allows for simultaneous management of the multiple defects of the aging lower eyelid and complete restoration of the relevant anatomy, while avoiding the common pitfalls of lower lid blepharoplasty. We present our experience of 64 patients who underwent bilateral combined septal-myocutaneous advancement flap and transconjunctival blepharoplasty. Indications and postoperative results are reviewed. No complications, including scleral show or ectropion, have been noted over the 4-year postoperative period.